Postoperative fever is defined as a temperature higher than 38 C (or greater than 100.4 F) on two consecutive postoperative days or higher than 39 C (or greater than 102.2 F) on any postoperative day. Knowledge of differential diagnosis, as well as a systematic approach, proves useful in narrowing down the differential diagnosis and instituting proper management.
Fever, as a manifestation of sepsis, should be promptly identified and managed appropriately to lower mortality rates in such cases.
The timing strongly influences etiology.
Postoperative fever is very common. The exact incidence of postoperative fever is not known, but the numbers are high. Estimates from different surgical procedures reveal that fever occurs early in the postoperative period anywhere from 20% to 90% of patients. In the majority of these cases, the fever usually occurs on the first or second day after surgery and has been linked to atelectasis. Postoperative fever is known to occur after all types of surgical procedures, irrespective of the type of anesthesia. The fever also occurs in children and both genders. Postoperative fever can occur after minor surgical procedures but is rare and depends on the type of procedure. Overall, both abdominal and chest procedures result in the highest incidence of postoperative fever.
Systemic Inflammatory Response Syndrome (SIRS):
Four criteria that include:
Two of the 4 criteria are needed to identify a patient with SIRS.
Two of the SIRS criteria plus a suspected source of sepsis is required to diagnose sepsis.
Signs of Organ Dysfunction
Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1.
Fever occurs in the first week (1 to 7 POD).
Fever occurs between postoperative weeks 1 and 4.
Fever after more than 4 weeks.
The above differential diagnosis is for causes that are categorized based on timing. However, there are many other causes that may have specific signs on physical exam and occur after specific surgery that are not included in the above differential.
Treatment can include oxygen, fluid balance, intravenous fluids, and a urinary catheter, or antibiotics.
As discussed earlier, the differentials are based on the timing of the fever, among other factors. Some of the important differentials are listed below.
In most patients, postoperative fever is due to a benign cause and resolves spontaneously. Patients who have atelectasis recover quickly once they are started on incentive spirometry and/or chest physical therapy. Patients with deep vein thrombosis and pulmonary embolism usually have a low-grade fever that resolves within a few days of treatment. The prognosis is worse for patients who have anastomotic leaks or bowel obstruction.
Failure to diagnose the cause of fever or identify the severity of it can lead the patient into SIRS, sepsis, severe sepsis, or septic shock. This can lead to prolonged hospitalization and even increase the mortality rate.
Patients who undergo general anesthesia should be advised to use incentive spirometry to prevent atelectasis, which is a common cause of postoperative fever. Early mobilization should also be encouraged in postoperative patients where allowed.
Postoperative fever is a common occurrence on all surgical floors. Because there are so many causes of fever, the problem is usually managed by an interprofessional team of healthcare professionals. The nurse is probably the first person who monitors the patient and discovers the fever. In order to know the cause, the nurse should first check the wound site, auscultate the lungs, and assess for deep vein thrombosis. Other causes of postoperative fever may be a urinary tract infection, an intravenous line (thrombophlebitis), or sepsis. Once the fever has been noted, the health care provider should be notified, and the workup depends on patient presentation and the day of the fever. If atelectasis is suspected, a chest x-ray may be ordered, blood and urine culture for sepsis, and a urinary tract infection and duplex ultrasound if a deep vein thrombus is suspected. The key is to examine the patient as it may provide a clue to the cause. (Level V)
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